Survey of attitudes of physicians toward the current evaluation and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD)

Abstract

We aimed in this study to determine the opinion of the medical directors of dialysis centers in the Kingdom of Saudi Arabia (KSA) about the updates of strategies for evaluation and treatment of chronic kidney disease-mineral and bone Disorder (CKD-MBD). A questionnaire was sent to medical directors of 174 dialysis centers in the KSA between July and November 2009. The questionnaire was opinion based and comprised the prevalence of the CKD-MBD, strategies of therapy and indications of cinacalcet, a new therapy in the CKD patients. A total of 154 medical directors of the 174 (88.5%), who are the therapeutic decision-makers for 10100 (89%) dialysis patients, answered the questionnaire. There were 84 respondents (54%) who believed that the parathormone (PTH) blood levels initially increase at a glomerular filtration rate (GFR) < 30%. There were 80 (53%) respondents who believed that changes of phosphorus (PO4) and cal-cium (Ca) blood levels are initially observed at GFR < 30 mL/min. The majority of respondents, 115 (77%), 116 (80%), 95 (66%), and 134 (90%) currently have observed increased prevalence of vascular calcifications, adynamic bone disease, PTH > 500 pmol/L, and elevated Ca blood levels, respectively, only in the minority of advanced CKD. However, 88 (58%) respondents observed increased prevalence of elevated PO4 blood levels in the majority of new dialysis and advanced CKD patients. There were 137 (89%) respondents who believed from the current published evi-dence that CKD-MBD may result in increased morbidity (e.g. fractures) and mortality (e.g. cardiovascular) in advanced CKD and new dialysis patients. However, only 41 (27%) respondents follow the PTH levels in their patients every 2-3 months, while 81(53%) follow it every 6 months. There were 127 (83%), 129 (84%), 114 (75%) respondents who would start vitamin D (vit D) in dialysis and CKD patients for hypocalcemia, high PTH, and vit D 1,25 deficiency, respectively. However, only 51 (34%) respondents would start vit D therapy for vit D 25 deficiency. There were 98 (75%), 73 (57%) 74 (59%), and 88 (68%) respondents who claimed that they could achieve control of calcium levels alone, control of PO4 levels alone PTH levels alone , and all parameters of CKD-MBD in > 50% of their patients, respectively. There were 126 (82%) and 126 (82%) respondents who agreed to the indications of the cinacalcet that include refractory secondary hyperparathyroidism of dialysis patients to vit D and diet and phosphate binders together, and when surgical parathyroidectomy is contraindicated or fail in this population, res-pectively. However, 127 (83%) and 139 (91%) respondents disagreed to the indications that include indiscriminate prescription to all CKD patients or off label to some early CKD patients, respectively. We conclude that the medical directors of the active dialysis centers in Saudi Arabia are well aware of the morbidity and mortality caused by the CKD-MBD in addition to the indications of vit D and phosphate binders and cinacalcet therapy. However, the study suggests inadequate assessment of the prevalence, patterns of CKD-MBD, and results of intervention in the CKD patients such as treatment of vit D 25 deficiency, and knowledge of the availability of cinacalcet for the treatment of CKD-MBD. More local studies and guidelines are required to disseminate information about the current patterns of CKD-MBD for better approach to the management of this disorder in the kidney centers in this country.